Effects of randomized supplementation of methionine or alanine on cysteine and glutathione production during the early phase of treatment of children with edematous malnutrition

BACKGROUND

We have shown that a low glutathione concentration and synthesis rate in erythrocytes are associated with a shortage of protein-derived cysteine in children with edematous severe acute malnutrition (SAM).

OBJECTIVE

We tested the hypothesis that methionine supplementation may increase protein-derived cysteine and upregulate cysteine synthesis, thereby improving glutathione synthesis during the early treatment of edematous SAM.

DESIGN

The cysteine flux, its de novo synthesis and release from protein breakdown, and erythrocyte glutathione synthesis rate were measured in 12 children with edematous SAM in the fed state by using stable isotope tracers at 3 clinical phases as follows: 3 ± 1 d (±SE) [clinical phase 1 (CP1)], 8 ± 1 d [clinical phase 2 (CP2)], and 14 ± 2 d (clinical phase 3) after admission. Subjects were randomly assigned to receive equimolar supplements (0.5 mmol ⋅ kg(-1) ⋅ d(-1)) of methionine or alanine (control) immediately after CP1.

RESULTS

In the methionine compared with the alanine group, cysteine flux derived from protein breakdown was faster at CP2 than CP1 (P < 0.05), and the change in plasma cysteine concentration from CP1 to CP2 was greater (P < 0.05). However, there was no evidence of a difference in cysteine de novo synthesis and its total flux or erythrocyte glutathione synthesis rate and concentration between groups.

CONCLUSIONS

Methionine supplementation increased cysteine flux from body protein but had no significant effect on glutathione synthesis rates. Although cysteine is made from methionine, increased dietary cysteine may be necessary to partially fulfill its demand in edematous SAM because glutathione synthesis rates and concentrations were less than previous values shown at full recovery. This study was registered at clinicaltrials.gov as NCT00473031.

Kwashiorkor and marasmus are both associated with impaired glucose clearance related to pancreatic β-cell dysfunction

Severe malnutrition is a major health problem in developing countries and can present as kwashiorkor or marasmus. Kwashiorkor is associated with septicaemia, profound metabolic changes including hepatic steatosis, altered protein metabolism and increased oxidative stress. Limited data suggest that children with kwashiorkor have an impaired glucose tolerance and insulin secretion. Our objective was to determine glucose tolerance in children with kwashiorkor compared to marasmus and its relation to insulin secretion and sensitivity. Six children with kwashiorkor and 8 children with marasmus were studied. We were also able to include 3 healthy children for comparison. They received a primed (13 mg/kg), constant infusion (0.15 mg/kg/min) of [6,6-(2)H(2)]glucose for 4 h with serial blood sampling. In addition, an oral glucose tolerance test (OGTT) was performed with labeled 10 mg/g [U-(13)C]glucose. Glucose clearance was determined using mathematical modeling. Glucose clearance rates during the OGTT were -392 (range 309) mL/kg in children with kwashiorkor, -156 (426) mL/kg in marasmus and 279 (345) mL/kg in the control group. Glucose clearance rates correlated with plasma albumin concentrations (r=0.67, P=.001). Insulin responses were strongly impaired in both kwashiorkor and marasmus. There was no indication of peripheral or hepatic insulin resistance in the malnourished groups. We show that glucose clearance rates are affected in both children with marasmus as well as kwashiorkor, which correlate with plasma albumin concentrations. The disturbed glucose clearance in malnutrition is related to an impairment in insulin availability.

Prevalence of Aflatoxins in Blood and Urine of Egyptian Infants with Protein–Energy Malnutrition

The aim of the present work was to study the presence of aflatoxins in blood and urine of infants with protein–energy malnutrition (PEM). The study was conducted on 60 infants, 30 with kwashiorkor and 30 with marasmus, with 10 age-matched healthy infants studied as a control group. Complete blood count, liver function tests, and determination of the level of aflatoxins (B1, B2, G1, G2, M1, M2, G2a, B3, GM1, P, and aflatoxicol R0) in blood and urine were carried out in all studied infants. Serum aflatoxins were detected in more infants with kwashiorkor (80%) than in those with marasmus (46.7%). The mean serum levels of total aflatoxins, AFB1, AFG1, and AFB2a, were significantly higher in infants with kwashiorkor (p <.001). Aflatoxin B1 (AFB1) was the most commonly detected type. The prevalence of aflatoxin excretion in the urine of infants with kwashiorkor was 80%, a higher value than that in infants with marasmus (46.7%). The mean urinary concentration of total aflatoxins followed the same pattern of distribution (p < .052). There were no significant differences between groups in the mean urinary concentrations of AFB1, AFG1, AFB2a, AFM1, and AFG2a. Aflatoxins were not detected in any of the serum or urine samples of the control group. Aflatoxins are highly prevalent in this study population and show a high degree of correlation with severe PEM.

Hepatic proteins and nutrition assessment

Serum hepatic protein (albumin, transferrin, and prealbumin) levels have historically been linked in clinical practice to nutritional status. This paradigm can be traced to two conventional categories of malnutrition: kwashiorkor and marasmus. Explanations for both of these conditions evolved before knowledge of the inflammatory processes of acute and chronic illness were known. Substantial literature on the inflammatory process and its effects on hepatic protein metabolism has replaced previous reports suggesting that nutritional status and protein intake are the significant correlates with serum hepatic protein levels. Compelling evidence suggests that serum hepatic protein levels correlate with morbidity and mortality. Thus, serum hepatic protein levels are useful indicators of severity of illness. They help identify those who are the most likely to develop malnutrition, even if well nourished prior to trauma or the onset of illness. Furthermore, hepatic protein levels do not accurately measure nutritional repletion. Low serum levels indicate that a patient is very ill and probably requires aggressive and closely monitored medical nutrition therapy.

The evaluation of serum leptin level and other hormonal parameters in children with severe malnutrition

OBJECTIVES

Protein-energy malnutrition (PEM) is a clinical problem caused by inadequate intake of one or more nutritional elements, and remains as one of the most important health problems in developing countries. The aim of this study is to determine the relationship among leptin concentrations, body weight and concentrations of some serum hormones, e.g., basal GH, IGF-1, basal cortisol and IGF-BP3, in severe malnourished children, and to determine the effects of leptin in malnourished children.

DESIGN AND METHODS

The study group consisted of 36 children diagnosed with PEM. Thirty healthy children were enrolled as the control group. After an overnight fast and before initiation of feedings, fasting venous blood samples were obtained from a forearm vein with needle technique for routine tests, and leptin, IGF-1, IGF-BP3, basal GH and cortisol levels were measured. Tests were carried out in the laboratories of the Department of Biochemistry by commercial kits.

RESULTS

Serum leptin levels of infants with marasmus and kwashiorkor were significantly lower than that of the controls (2.09 +/- 0.93 and 2.27 +/- 1.01, 6.82 +/- 2.28 ng/ml, respectively, P < 0.001). However, there was no significant difference between serum leptin levels in children with marasmus and those with kwashiorkor (P > 0.05). Serum IGF-1 and IGF-BP3 levels were significantly lower in malnourished children (P < 0.001, both). Also, basal GH and cortisol levels were significantly higher in malnourished children (P < 0.001, both). There was a positive correlation among serum leptin levels and IGF-1 and IGF-BP3 levels and also a negative correlation among serum leptin levels and basal GH and cortisol levels in children diagnosed with marasmus or kwashiorkor and the control group.

CONCLUSIONS

The decrease of energy intake and adipose tissue and serum IGF-1 levels in children with PEM may result in decrease of leptin secretion. Decrease in serum leptin levels may initiate food intake by increasing appetite and stimulating the secretion of cortisol and GH that might increase energy expenditure through an autocrine mechanism. Moreover, serum leptin level may be an important signal to reflect the metabolism of children with PEM.

Selenium serum concentrations in malnourished Ecuadorian children: a case-control study

Little is known about the selenium status of children living in the Andean regions of South America, which commonly have volcanic soil with low selenium content. Human selenium deficiency has been hypothesized to have a negative impact on immune function and to increase the risk of infection. The objective of this study was to evaluate the serum selenium concentrations of severely malnourished children living in urban and rural Andean Ecuador, and to compare them to a control group of normally nourished children from the same communities. Forty-three children, aged six to 36 months, with marasmus or kwashiorkor and 30 control children were enrolled from July to November 1993 in Quito, Ecuador. Serum selenium concentrations were lower in the children with marasmus (0.91 +/- 0.28 microM/L, n = 21) and kwashiorkor (0.37 +/- 0.15 microM/L, n = 22) than in those who were normally nourished (1.77 +/- 0.75 microM/L, n = 30, p < 0.001 for each difference). The serum selenium concentrations in children with kwashiorkor were significantly lower than those in children with marasmus (p < 0.001). All 22 of the children with kwashiorkor, 15 of the 21 children with marasmus, and five of the 30 normal children had serum levels < 1.08 microM/L (8.5 micrograms/dL) (chi 2 = 38.4, p < 0.00000001). In the Andean regions of Ecuador, selenium deficiency is prevalent in children with protein and caloric deficiency. Furthermore, 17% of Ecuadorian children with normal weight-for age-Z score are selenium-deficient.

Pro-inflammatory cytokines in Turkish children with protein-energy malnutrition

BACKGROUND

Protein-energy malnutrition (PEM) results from food insufficiency as well as from poor social and economic conditions. Development of PEM is due to insufficient nutrition. Children with PEM lose their resistance to infections because of a disordered immune system. It has been reported that the changes occurring in mediators referred to as cytokines in the immune system may be indicators of the disorders associated with PEM.

AIMS

To determine the concentrations of pro-inflammatory cytokines in children with PEM, and to find out whether there was an association with the clinical presentation of PEM.

METHODS

The levels of serum total protein, albumin, tumour necrosis factor-alpha, and interleukin-6 were measured in 25 patients with PEM and in 18 healthy children as a control group. PEM was divided into two groups as kwashiorkor and marasmus. The kwashiorkor group consisted of 15 children and the marasmus group consisted of 10 children.

RESULTS

Levels of serum total protein and albumin of the kwashiorkor group were significantly lower than both the marasmus group and controls (p < 0.05). In view of tumour necrosis factor-alpha levels, there was no difference between groups (p > 0.05). While levels of interleukin-6 in both the marasmus group and the kwashiorkor group were significantly higher compared with controls (p < 0.05), there was no significant difference between the groups of marasmus and kwashiorkor (p > 0.05).

CONCLUSIONS

It was observed that the inflammatory response had increased in children with malnutrition.

Cysteine supplementation improves the erythrocyte glutathione synthesis rate in children with severe edematous malnutrition

BACKGROUND

Children with severe edematous malnutrition have higher than normal oxidant damage and lower concentrations of the antioxidant reduced glutathione (GSH), which are associated with slower synthesis of GSH and with low extra- and intracellular concentrations of the precursor amino acid cysteine.

OBJECTIVE

We tested whether early dietary supplementation with cysteine could restore a normal GSH concentration and synthesis rate in these children.

DESIGN

Erythrocyte cysteine and GSH concentrations and the fractional and absolute synthesis rates of GSH were measured in 2 groups of 16 edematous malnourished children, 10 boys and 6 girls aged 6-18 mo, at 3 times after hospital admission: at approximately 2 d (period 1), when they were malnourished and infected; at approximately 11 d (period 2), when they were malnourished but cleared of infection; and at approximately 50 d (period 3), when they had recovered. Supplementation with either 0.5 mmol. kg(-1). d(-1) N-acetylcysteine (NAC group) or alanine (control group) started immediately after period 1 and continued until recovery.

RESULTS

From period 1 to period 2 the concentration and the absolute synthesis rate of GSH increased significantly (P < 0.05) in the NAC group but not in the control group. The increases in the GSH concentration and synthesis rate were approximately 150% and 510% greater, respectively, in the NAC group than in the control group. The increases in the NAC group were associated with a significant effect of supplement (P < 0.03) on erythrocyte cysteine concentration.

CONCLUSION

These results suggest that the GSH synthesis rate and concentration can be restored during the early phase of treatment if patients are supplemented with cysteine.

Serum concentrations of sex hormone binding globulin are elevated in kwashiorkor and anorexia nervosa but not in marasmus

BACKGROUND

Customary blood protein markers for malnutrition are of limited value in the diagnosis of protein-energy malnutrition or anorexia nervosa in children and in the follow-up to refeeding in such children.

OBJECTIVES

For these diseases, we compared the diagnostic value of sex hormone binding globulin (SHBG) with that of albumin, transferrin, transthyretin, and retinal binding protein and determined the relations between concentrations of insulin, insulin-like growth factor I, and SHBG.

DESIGN

SHBG was assayed in children with protein-energy malnutrition (29 children with kwashiorkor and 28 with marasmus), in 29 anorectic girls (before and after refeeding), and in age- and sex-matched control subjects.

RESULTS

Mean (+/-SE) serum SHBG concentrations were higher in the children with kwashiorkor (0.18 +/- 0.07 micromol/L) than in the children with marasmus (0.11 +/- 0.05 micromol/L, P < 0.0001) or the control subjects (0.11 +/- 0.03 micromol/L, P < 0.0005). In the children with anorexia nervosa before weight gain, serum SHBG concentrations were significantly higher (0.10 +/- 0.04 micromol/L) than in the age-matched control subjects (0.06 +/- 0.03 micromol/L, P < 0.001) and decreased significantly after 30 d of refeeding (0.04 +/- 0.01 micromol/L, P < 0.0001). This decrease was negatively correlated with insulin-like growth factor I but not with insulin. Mean serum SHBG concentrations were influenced neither by inflammation, as indicated when C-reactive protein was used as a marker (0.27 +/- 0.27, 0.34 +/- 0.42, and <0.04 micromol/L in the children with marasmus, kwashiorkor, and anorexia nervosa, respectively), nor by glomerular filtration, as indicated when cystatin-C was used as a marker (68.46 +/- 23.08, 66.90 +/- 43.08, and 49.23 +/- 7.69 micromol/L, respectively).

CONCLUSIONS

The high SHBG concentration observed in anorexia nervosa and kwashiorkor seems to be of multifactorial origin. For these 2 diseases, SHBG is a reliable marker of nutritional status, is unrelated to either C-reactive protein or cystatin-C, and may be helpful in distinguishing kwashiorkor from marasmus and as a follow-up marker after refeeding.

Prostaglandin E2 is raised in kwashiorkor

OBJECTIVE

Infection is a common occurrence in children with kwashiorkor. It has been suggested that infection in kwashiorkor results from immune depression, and that the immune depression of kwashiorkor is caused by a diet-associated elevation of prostaglandin E2 (PGE2). The purpose of this study was to determine whether levels of PGE2 are abnormal in children with kwashiorkor.

SETTING AND SUBJECTS

Plasma PGE2 and plasma proteins were measured in children admitted with oedematous kwashiorkor, and compared with PGE2 in children with cerebral palsy.

RESULTS

Plasma PGE2 was higher in children with kwashiorkor than in control children (7.25 +/- 3.5 v. 3.51 +/- 1.59, P < 0.01). Within the kwashiorkor study group there was a significant negative correlation between log-transformed serum PGE2 and total plasma protein (r = -0.59, P < 0.001), plasma albumin (r = -0.63, P < 0.001), weight-for-age (r = -0.37, P < 0.05), and height-for-age (r = -0.37, P < 0.05). The difference in mean values of PGE2 in children with kwashiorkor who recovered from the illness and those who died was not significant (7.1 +/- 2.6 v. 9.1 +/- 4.8, P = 0.36).

CONCLUSION

Significantly higher PGE2 levels in children with kwashiorkor provide adequate reason for the depression of immune function known to occur in these children. Elevated PGE2 levels may also be implicated in other components of the illness.

Selenium status, kwashiorkor and congestive heart failure

Selenium deficiency is associated with congestive heart failure (CHF) in geographic areas where dietary selenium intake is low and in individuals receiving total parenteral nutrition. Among 66 children with kwashiorkor (including marasmic-kwashiorkor), those who developed CHF had lower serum selenium concentrations than those who did not (32.9 +/- 8.3 vs 41.1 +/- 11.9 microg/L, mean +/- SD, p = 0.03). This association was independent of serum albumin and selenium status was not associated with severity of symptoms, anthropometric indices or HIV infection.

CONCLUSION

This association raises the possibility that selenium may contribute to CHF in washiorkor.

[Effects of vitamin A supplementation on nutritional markers on the follow-up of malnutrition in children]

Prospectively assessment of vitamin A supplemented during a follow-up of a protein-energy malnutrition rehabilitation included serum retinol, Retinol Binding Protein (RBP) and prealbumin (PA) determination. This study was conducted during one month on a group of 36 vitamin A (200,000 IU) supplemented malnourished children and 32 age-and sex-matched malnourished children receiving only a nutritional regimen. Determinations were carried out at days 0, 15 and 30. Protein marker concentrations increased steadily in supplemented children as compared to those in the untreated group (p < 0.05, Student's t test). On the other hand, serum concentrations of the two proteins progressively regained normal values in the vitamin A supplemented group. Data also showed that retinol supplementation in conjunction with an appropriate nutritional diet is effective in raising serum concentrations of vitamin A and its binding proteins to normal levels. Therefore, we concluded that the results of this study demonstrates the importance of vitamin A supplementation in the management of these deficiency states.

The pharmacokinetics of caffeine in Nigerian children suffering from malaria and kwashiorkor

OBJECTIVES

Caffeine-containing beverages are generally consumed by Nigerians suffering from malaria and kwashiorkor in the belief that caffeine aids early recovery from these illnesses, which are common in the tropics. However, there are no studies on the influence of these diseases on the absorption and pharmacokinetics of caffeine in Africans.

MATERIALS AND METHODS

A single oral dose of caffeine was given to five healthy children and to five and seven children suffering from malaria and kwashiorkor, respectively. Caffeine and its dimethylxanthine metabolites were measured in plasma using high-performance liquid chromatography.

RESULTS

The maximum plasma concentration (Cmax) of caffeine and the time of Cmax were similar (P > 0.05) in the three groups. However, the elimination half-life of caffeine was significantly longer in children with malaria (9.2 +/- 3.5 h) (P < 0.01) and kwashiorkor (13.1 +/- 7.9 h) (P < 0.05) than in the healthy controls (3.7 +/- 1.8 h). The total plasma oral clearance of caffeine of 4.4 +/- 1.9 ml/min/kg in healthy children was significantly higher (P < 0.01) than in those with kwashiorkor (2.0 +/- 0.9 ml/min/kg) and malaria (1.6 +/- 1.0 ml/min/ kg) (P < 0.05). Paraxanthine was the principal metabolite in all the three groups with Cmax significantly higher in healthy children (1.3 +/- 0.3 microg/ml) than in children with malaria (0.8 +/- 0.4 microg/ml) (P < 0.05) and kwashiorkor (0.3 +/- 0.1 microg/ml) (P < 0.0001). CYP1A2 activity, measured by the plasma ratios of paraxanthine: caffeine, was significantly lower in kwashiorkor and malaria.

CONCLUSIONS

This study showed that the plasma kinetics of caffeine are significantly altered in malaria and kwashiorkor, and CYP1A2 activity was lower in these two disease groups.

In vivo rates of erythrocyte glutathione synthesis in children with severe protein-energy malnutrition

Although the compromised GSH status of children with edematous protein-energy malnutrition (PEM) has been documented, the in vivo kinetic mechanism(s) responsible for this is not known. To determine if decreased synthesis contributes to the alteration of GSH homeostasis, the fractional and absolute rates of synthesis of erythrocyte GSH were determined shortly after admission (study 1), approximately 9 days postadmission (study 2), and at recovery (study 3) in seven children with edematous PEM and seven children with nonedematous PEM. Children with edematous PEM had significantly lower erythrocyte GSH and slower absolute rates of GSH synthesis than children with nonedematous PEM both shortly after admission, when they were both malnourished and infected, and approximately 9 days later, when the infection had resolved but they were still malnourished. At these times, the edematous group also had significantly lower erythrocyte GSH concentrations and absolute rates of synthesis than at recovery. Plasma and erythrocyte-free cysteine concentrations of the edematous group were significantly lower at studies 1 and 2 than at recovery. In contrast, erythrocyte GSH concentrations, rates of GSH synthesis, and plasma and erythrocyte free cysteine concentrations of the nonedematous group were similar at all three time points and greater at studies 1 and 2 than in the edematous group. These results confirm that GSH deficiency is characteristic of edematous PEM and suggest that this is due to a reduced rate of synthesis secondary to a shortage in cysteine.

Plasma fatty acids in children with grade III protein-energy malnutrition in its different clinical forms: marasmus, marasmic kwashiorkor, and kwashiorkor

Plasma fatty acid patterns were analysed in 15 children aged 2 to 42 months (median = 12 months) admitted to the University Hospital, Faculty of Medicine of Ribeirão Preto, University of São Paulo, suffering from grade III protein-energy malnutrition in its different clinical forms: marasmus (n = 5), marasmic kwashiorkor (n = 5), and kwashiorkor (n = 5). A control group of eight children from the same population aged 3 to 22 months (median = 12 months) was also studied. Plasma fatty acids were analysed by gas liquid chromatography. The plasma fatty acid patterns detected in grade III protein-energy malnutrition indicated changes characteristic of essential fatty acid deficiency, with lower linoleic acid (C18:2) levels in the three groups (p < 0.05). The major metabolite of linoleic acid, arachidonic acid (C20:4), was lower in the kwashiorkor group than in the control group (p < 0.05). Linoleic acid (C18:2) levels were lower in the marasmus group than in the kwashiorkor group (p < 0.05). Several factors may have contributed to these changes, such as a decreased content of linoleic acid in the diet, plus malabsorption and/or poor utilization of fats, and changes in the synthesis or degradation of these fatty acids. Although many questions remain unanswered, we suggest that an adequate amount of linoleic acid be added to the rehabilitation diet of these children in the form of vegetable fat.

Leucocyte migration inhibition factor (L-MIF) in malnourished Nigerian children

Leucocyte Migration Inhibition Factor (L-MIF) was measured in 41 children with marasmus, 19 with kwashiorkor, 5 with marasmic-kwashiorkor and 35 well-fed healthy children serving as controls. For L-MIF assay, two different antigens (live attenuated measles virus vaccine and diptheria pertussis tetanus (DPT) vaccine were used. Percentage migration indices obtained with the two antigens were significantly higher in the malnourished than in the well-fed healthy sex and age-matched controls (P < 0.01). The total serum protein and albumin concentrations were significantly reduced in the malnourished children compared with the controls (P < 0.01). Mean total leucocyte numbers were not significantly different in marasmic and marasmic-kwashiorkor children compared with the controls (P > 0.21).

Serum thyroid hormone and thyroid gland weight measurements in protein-energy malnutrition

Protein-energy malnutrition (PEM) is a problem which concerns about half the world's children. We investigated the effects of malnutrition on thyroid gland weight and thyroid hormone levels. 22 children suffering from malnutrition (14 children suffering from marasmus and 8 children suffering from kwashiorkor) and 7 healthy controls were studied. Malnutrition was confirmed clinically and according to the Wellcome classification definition of malnutrition. Serum thyroid hormone concentrations were measured by radioimmunoassay and the weights of the thyroid gland were evaluated scintigraphically. In the groups with marasmus and kwashiorkor the mean TT4, TT3 and FT3 levels were significantly lower, and TSH levels were significantly higher, compared to controls. FT4 was not influenced by PEM. The mean thyroid gland weights of the groups with marasmus and kwashiorkor were higher than that of the control group. We found no significant differences in all these parameters between groups with marasmus and kwashiorkor. In each of the three groups, the most marked positive correlation was between thyroid gland weight and ratio of thyroid gland weight to body surface area.

Serum transaminases and isocitric dehydrogenase in kwashiorkor

Serum glutamic oxalacetic transaminase (G-OT), glutamic-pyruvic transaminase (G-PT), and isocitric dehydrogenase (ICD) have been estimated in six groups of subjects, namely, normal British adults, normal Nigerian adults, undernourished Nigerian adults and children, Nigerian children with florid protein malnutrition (kwashiorkor), and cases of protein malnutrition after treatment. The normal range in Nigerian adults was apparently slightly lower than in European adults.A marked increase in serum enzyme activity was found in florid malnutrition, and a slight rise in undernutrition. In all cases serum G-PT showed lesser changes than G-OT and ICD. The causes of these abnormalities are discussed. The increased serum enzyme activity is thought to be derived primarily from the liver and possibly also from voluntary muscle. Estimation of serum enzymes is recommended in the investigation of protein malnutrition.

Plasma concentration of taurine is higher in malnourished than control children: differences between kwashiorkor and marasmus

Plasma free amino acids were determined in the plasma of severely malnourished children under two years of age. A total of thirty-one patients and eleven controls were evaluated: seventeen cases of kwashiorkor, eight cases of marasmus, and six cases of marasmic-kwashiorkor. Fasting plasma samples were taken in the morning on the day of admission. Fasting plasma samples were also taken from nine patients at discharge after two months in the hospital where they received a balanced diet as treatment. A partial reversal of the signs of malnutrition was observed at discharge. In the whole group of patients ad admission, lower concentrations of tyrosine, methionine, tryptophan, and leucine and higher concentrations of aspartate, glutamate, and taurine were observed compared to controls. Taurine continued to be elevated in the malnourished group at the time of discharge. Marasmic children, as compared to controls, had high aspartate and low tryptophan levels, but taurine levels were not significantly different from controls. Kwashiorkor patients had low tyrosine, methionine, tryptophan, and lysine, and significantly higher taurine plasma levels. The elevated concentration of taurine might be the result of a redistribution of this amino acid to provide specific tissues with the required amount for development.

A case of kwashiorkor in the UK

A case of kwashiorkor in a British child of Caucasian origin is described. The 5-year-old boy was referred to hospital for investigation of a persistent anaemia, but on examination was found to have classical features of kwashiorkor. He was stunted with both height and weight below the fifth centile and had mild pitting oedema in both legs. His hair was pale and easily pluckable and a soft liver edge was palpable. Plasma albumin concentration was 16 g/l and the plasma amino acid pattern, which revealed markedly reduced levels of essential but normal to high non-essential amino acids, was similar to that described in kwashiorkor in Uganda. A dietary history revealed that for about 2 years the child's diet had contained very little protein but adequate energy and had been supplemented with multivitamin pills. There was no evidence of other pathology, neglect or abuse and the child responded rapidly to refeeding with a balanced diet.

Whole-body protein kinetics in children with kwashiorkor and infection: a comparison of egg white and milk as dietary sources of protein

This study tested the hypothesis that during treatment of kwashiorkor (including marasmic kwashiorkor) with infection there is a lower rate of amino acid oxidation when the dietary intake of amino acids resembles the amino acid composition of acute phase proteins (APPs). Twenty-two children in Blantyre, Malawi, with kwashiorkor and acute infection were fed an isoenergetic, isonitrogenous diet with either egg white or milk as a protein source. The whole-body amino acid oxidation rate was measured after 24 h by determining the plasma urea rate of appearance, and whole-body protein breakdown and synthesis rates were determined from the plasma leucine rate of appearance. Plasma concentrations of C-reactive protein, alpha1-antitrypsin, tumor necrosis factor alpha (TNF-alpha), and interleukin 6 (IL-6) were determined on admission and at 24 and 48 h. The 11 children who received milk had a lower rate of amino acid oxidation than the children who received egg white (x +/- SD: 137 +/- 65 compared with 195 +/- 66 micromol urea x kg body wt(-1) x h(-1), P < 0.05). No significant differences were found between the two groups in the rate of whole-body protein breakdown or protein synthesis. The TNF-alpha concentration correlated inversely with whole-body protein breakdown and synthesis rates, and the IL-6 concentration correlated directly with C-reactive protein. We conclude that by making the amino acid composition of the diet resemble that of APPs in the treatment of acute kwashiorkor, the rate of amino acid oxidation can be decreased.

Inflammatory mediators in children with protein-energy malnutrition

Edema is a typical sign in kwashiorkor, which is present in a subset of patients with protein-energy-malnutrition (PEM). The pathophysiology of this edema is not well established. One of the abnormalities found in kwashiorkor is reduced concentrations of antioxidants, suggesting a compromised capacity to neutralize free radicals, which are known to induce tissue damage. We have studied plasma concentrations of several mediators of the inflammatory cascade. Concentrations of interleukin 6 (IL-6), C-reactive protein, and the soluble receptors of tumor necrosis factor alpha (sTNFR-p55 and sTNFR-p75) are greater in children with PEM, particularly in those with kwashiorkor, whereas soluble receptors of IL-6 (sIL6R-gp80) and IL-1 receptor antagonist concentrations are not significantly different from those of healthy children. In addition, concentrations of IL-6, sTNFR-p55, and sTNFR-p75 are greater in kwashiorkor patients irrespective of the presence of infection. Antioxidant status, as determined by plasma concentrations of glutathione and vitamin E, is significantly reduced in kwashiorkor patients. These data support the notion that children with edematous malnutrition show increased inflammatory reactivity that may contribute to edema formation.

Assessment of plasma fibronectin in malnourished Nigerian children

BACKGROUND

Severe malnutrition is associated with septic infections. The concentrations of fibronectin, albumin, and transferrin in plasma were measured in three groups of children with protein-energy malnutrition, aged 1-3 years, each group comprising 20 children. The aim of which was to test whether plasma fibronectin, being an opsonic protein, was reduced in such children, and if it was a useful index for assessing the severity of malnutrition.

METHODS

The concentrations of fibronectin, albumin, and transferrin in plasma were studied by enzyme immunoassay/ immunoblotting, spectrophotometry and immunoturbidimetry respectively.

RESULTS

All values were significantly lower in the patients with malnutrition than in the age- and sex-matched well-nourished Nigerian reference children. Within the malnourished group, the fibronectin value was evenly reduced in all subgroups. Albumin and transferrin values were lowest in the patients with kwashiorkor, highest in the marasmic patients, and intermediate in the patients with marasmic kwashiorkor; the values correlated mutually in individual cases as well, but not with the fibronectin levels. Neither plasma fibronectin fragmentation nor tissue fibronectin was detected in any patient with malnutrition or in the reference subjects.

CONCLUSIONS

The reduced plasma fibronectin values in these patients may be due to reduced synthesis by the liver, as evidenced by the equally reduced albumin and transferrin concentrations and/or to the multiple infections characteristic of the patients.

Pharmacokinetics of amikacin in children with kwashiorkor

The pharmacokinetics of intravenous amikacin, administered as a mean (SD) bolus dose of 5.5 (1.2) mg/kg to children between the ages of 1 and 4 years with kwashiorkor, was studied. Although there was a tendency for the average volume of distribution to increase to the upper limit of normal, plasma elimination half-life, first order elimination-phase rate constant and clearance remained close to the reference values for adults. Despite marginal elevation of the average t1/2 beta-value, reflecting a general trend, renal impairment in respect of amikacin clearance could not be demonstrated. It was concluded that the changes in pharmacokinetic parameters found in kwashiorkor are not large enough to amend the current therapeutic regimens for amikacin in this condition.

Polyunsaturated fatty acids in erythrocyte and plasma lipids of children with severe protein-energy malnutrition

The fatty acid composition of plasma cholesterol esters, plasma phospholipids, erythrocyte phosphatidylcholine and erythrocyte phosphatidylethanolamine was investigated in severely malnourished Nigerian children with kwashiorkor (n = 12) and marasmus (n = 32). Normally nourished children from the same area (n = 23) served as controls. The malnourished children showed a significant reduction of highly polyunsaturated fatty acids in cholesterol esters, phospholipids and phosphatidylcholine. No differences between the groups were found in erythrocyte phosphatidylethanolamine. Children with kwashiorkor had lower levels of linoleic acid metabolites and docosahexaenoic acid than marasmic children. The results suggest that the kwashiorkor syndrome is associated with impaired desaturation and elongation of PUFA and/or increased lipid peroxidation.

Misplaced iron in kwashiorkor

OBJECTIVES

To determine the presence of radical promoting iron (non-protein-bound or loosely bound or free iron) in the plasma of children with kwashiorkor.

DESIGN

The bleomycin assay was employed for the quantitation of free or loosely bound iron.

SETTING

The Red Cross War Memorial Children's Hospital, Cape Town, Tertiary Care.

SUBJECTS

Fifty children on admission with kwashiorkor: six with marasmus and twelve healthy well-nourished controls.

RESULTS

Non-protein-bound iron was detected in the plasma of 58% of children with kwashiorkor but was absent in marasmic and healthy well-nourished children.

CONCLUSIONS

The presence of radical promoting iron supports the hypothesis that a free radical injury probably plays a role in the pathogenesis of kwashiorkor and its removal may improve mortality.

Serum amino acids and genesis of protein energy malnutrition

Twenty four patients of classical marasmus and kwashiorkor along with equal number of healthy controls were selected for the study. Their serum amino acid patterns analysis revealed a mean ratio of glutamate to alanine in fasting samples of normal individuals to be 0.33, while it as 9.3 in kwashiorkor and 1.6 in marasmus. This differences in controls, kwashiorkor and marasmus was statistically significant. This observation may explain evolution of marasmus and kwashiorkor in children with similar diets. On the basis of the present observation it is postulated that in kwashiorkor, the conversion of pyruvate to alanine in presence of glutamate, an aminogroup donor does not proceed normally, resulting in accumulation of glutamate and low alanine. Thus the development of marasmus and kwashiorkor may not be related to dietary inadequacy alone but also to the transaminase function. This could be genetic in origin.

Glutathione and association antioxidant systems in protein energy malnutrition: results of a study in Nigeria

Marasmus and kwashiorkor are manifestations of protein energy malnutrition. The pathophysiology of these disorders is poorly understood. We studied a number of blood antioxidants [glucose-6-phosphate dehydrogenase (G6PDH), glutathione reductase (GR) and its cofactor flavin adenine dinucleotide (FAD), the tripeptide glutathione as the major nonprotein thiol], serum albumin, and retinol-binding protein in 12 children suffering from kwashiorkor with all classical symptoms, in 13 patients with clinically severe marasmus, in 19 marasmic but active children, and in 23 controls. Significant changes were observed for erythrocyte glutathione and correspondingly for nonprotein thiols in whole blood (0.72 +/- 0.29 mM thiols in controls, 0.50 +/- 0.22 mM in marasmus, 0.35 +/- 0.23 mM in severe marasmus, and 0.22 +/- 0.13 mM in kwashiorkor). These differences were paralleled by a decrease in serum albumin concentration so that the molar ratio of nonprotein thiols/albumin had an average value of approximately 1.5 in all groups. The erythrocyte glutathione-reducing system, represented by G6PDH and glutathione reductase, showed only slight differences among the four groups of children; the supposition that kwashiorkor occurs predominantly in children with aberrant G6PDH could not be substantiated. Unexpectedly, erythrocyte FAD, an index of riboflavin status, was normal in most malnourished patients. Discussed is the prospect of administering glutathione in kwashiorkor patients.

In vitro lymphocyte-differentiating effects of thymulin (Zn-FTS) on lymphocyte subpopulations of severely malnourished children

This work investigates how thymic dysfunction contributes to the depression of cell-mediated immunity in protein-energy malnutrition (PEM). In Bolivian children hospitalized for severe PEM, the size of the thymus was measured by echography, and the lymphocyte subpopulations were detected by using monoclonal antibodies. These data were compared with those obtained from healthy control subjects. Regardless of the clinical form of PEM, our results show a high degree of T lymphocyte immaturity in severely malnourished children, which correlates with a severe involution of the thymus. Before in vitro incubation with thymulin, this significant increase in the percentage of circulating immature T lymphocytes was concomitant with a decrease in mature T lymphocytes and a slight increase in cytotoxic T subpopulations. After in vitro incubation with thymulin, immature T lymphocytes decreased and mature T lymphocytes increased.

Apparent hypocalcaemia in Nigerian children with kwashiorkor

Thirty children with kwashiorkor had a mean +/- SEM plasma calcium (Ca) of 7.15 +/- 0.10mg/100ml; total proteins (TP) of 4.60 +/- 0.17g/100ml and albumin (A) of 1.89 +/- 0.11g/100ml. These values are significantly lower (p < 0.001) than the corresponding values of 9.07 +/- 0.10; 7.30 +/- 0.11 and 3.85 +/- 0.07 observed in thirty other age-matched normal controls. No significant differences exist in the plasma alkaline phosphatase (AP) levels in both groups. Correction of calcium for hypoalbuminaemia in the kwashiorkor group revealed that the observed hypocalcaemia in kwashiorkor is merely apparent.

Plasma free carnitine levels in children with malnutrition

In this study, plasma free carnitine and albumin levels were measured in children with protein-energy malnutrition (PEM). A total of 71 children with malnutrition were studied. The control group consisted of 20 healthy children. The mean plasma carnitine level was 78.4 +/- 1.94 nmol/ml in the control group. Marasmus and kwashiorkor patients displayed lower plasma free carnitine values, which were found to be statistically significant when compared to those of the control (P < 0.001). However, the values were significantly lower in kwashiorkor patients than in marasmic cases (29.7 > 5.46). There was no correlation between serum albumin and free carnitine levels in cases with kwashiorkor.

[Effects of refeeding on serum immunoglobulin (IgA, IgG, IgM) concentrations in children with severe protein-energy malnutrition]

BACKGROUND

Published studies on the serum immunoglobulin concentrations of patients with protein-energy malnutrition (PEM) have been contradictory. This report describes such a study in 21 Senegalese children.

POPULATION AND METHODS

Twenty one Senegalese infants (mean age: 19 +/- 2 months) with severe PEM were included in the study. Their weight was less than 32% of the normal range-for-height and all had sparse, thin hair and dyspigmentation of the skin. They were all suffering from hypoproteinemia (less than 70% of normal) and hypoalbuminemia (less that 61% of normal). The presence or absence of edema, loss of subcutaneous fat and mental changes were used to classify them into three groups. 1) kwashiorkor: eight infants; 2) marasmus: eight infants; 3) kwashiorkor plus marasmus: five infants. The control group comprised 27 infants living in the same area and having the same dietary habits as the 21 sick infants. The 21 infants with malnutrition were refed for 3 weeks with a diet supplying 100-150 Kcal/kg/d and 5-8 g/kg/d protein. The plasma concentration of proteins, prealbumin and immunoglobulins was measured on days 0, 8, 15 and 21.

RESULTS

The only significant change was in the IgG concentrations of group 1, which increased to normal levels by day 15 as did the total protein and prealbumin.

CONCLUSION

Severe PEM can lead to a loss of one class of immunoglobulins, but this can be restored by refeeding.

Aflatoxin, kwashiorkor, and morbidity

Children suffering from kwashiorkor could be grouped as those in whom aflatoxin was detectable in both serum and urine, and those in whom this mycotoxin was undetectable. Examination of the clinical records of the aflatoxin-positive and -negative children (58% and 42% of the sample, respectively) showed several other differences between the two groups. Compared with the aflatoxin-negative group, the children scored as aflatoxin-positive showed a significantly lower haemoglobin level (P = 0.02), a longer duration of oedema (P = 0.057), an increased number of infections (P = 0.037), and a longer duration of hospital stay (P = 0.008). The present findings suggest that the consumption of a staple food such as maize that is contaminated with the fungus Aspergillus flavus exposes susceptible kwashiorkor children to the metabolic hazards of aflatoxins, resulting in a greater risk of frequent infections.

Selenium in malnourished Sudanese children: status and interaction with clinical features

Plasma selenium (Se), haemoglobin (Hb) and packed cell volume (PCV) were measured in 53 malnourished Sudanese children, age 6-36 months, and 11 children who had tuberculosis. Twelve healthy well-nourished children served as controls. The mean (+/- SD) plasma Se (mg/kg) was 0.05 (0.036), 0.070 (0.040), 0.063 (0.015), 0.73 (0.012), 0.082 (0.014) in children with kwashiorkor/marasmic kwashiorkor (oedematous group), marasmus, tuberculosis and healthy controls. The mean Se level in the various groups showed a significant difference (p < 0.002). Whereas the oedematous group differed significantly from the rest, there was no difference between the means of the marasmic, underweight, tuberculosis patients and controls. The mean plasma albumin (+/- SD) in oedematous group was 19.6 (6.6) g/l and ranged between 22.6 (5.0) and 33.1 (3.0) in the other groups. A significant positive correlation was found between plasma Se level, albumin, Hb and PCV (respectively, r = 0.46, p < 0.0001; r = 0.37, p < 0.001; r = 0.36, p < 0.002).

Elevated glutathione S-transferase activity in erythrocytes from malnourished children

Glutathione S-transferases (GSTs) are principally involved in detoxification. These enzymes can be induced by an increased flux of substrate, such as occurs during pro-oxidative stress or antioxidant deficiency. We tested the hypothesis that the postulated oxidative stress in severe malnutrition would result in induction of GSTs in erythrocytes. Erythrocyte GST activity towards 1-chloro-2,4-dinitrobenzene (CDNB) was measured in 271 malnourished children (22 undernourished; 92 marasmic; 82 kwashiorkor; 75 marasmic-kwashiorkor) and 48 healthy children. GST activity in the malnourished children was significantly higher than the control group (P < 0.01). The GST activity in the four classes of malnutrition did not differ. There was a weak relationship between GST activity and the height deficit, but not with the weight deficit, or the clinical features displayed by the children. The 11 children that died had a higher value than the survivors. There was no change in GST with anthropometric recovery. We conclude that erythrocyte GST has been induced in children with malnutrition. Induction of erythrocyte GST may be the result of exposure of the children to oxidative stress during the months prior to their presentation with severe malnutrition.

Lipids and lipoproteins of malnourished children during early renutrition: apolipoprotein A-IV as a potential index of recovery

Twenty-six children with marasmus and 27 with kwashiorkor were compared with 23 control children of matching ages. Kwashiorkor was characterized by increased phospholipids (NS), low (P < 0.01) apolipoprotein (apo) B-rich LDL, and near normal apo A-I and HDL-C. In children with marasmus apo B (P < 0.02) LDL-C (NS), apo A-I (P < 0.01), and HDL-C (P < 0.001) decreased. Fifteen children in each group were followed for 2 wk. Control values were progressively reached after 2 wk. In the younger children final apo B was higher than in control subjects (P < 0.03) but apo A-I was identical. Apo A-IV, assayed because it correlates with the functional state of intestine, was near normal in children with kwashiorkor and decreased with treatment. In children with marasmus apo A-IV decreased by 50%, increased with treatment in older children, but further diminished in younger children. After 2 wk apo A-IV was significantly lower in all patients than in control subjects. Apo A-IV, by remaining depressed after other variables normalized, seems a good index of nutritional status.

Role of zinc supplementation in the rehabilitation of severely malnourished children

A double-blind study was conducted to assess the role of zinc supplementation in the rehabilitation of severely malnourished children. Thirty-three children with severe protein-energy malnutrition received either 40 mg of zinc as zinc sulphate or a placebo during their rehabilitation in addition to the diet containing about 700 kJ and 3-4 g protein per kg body weight/day. Their clinical and biochemical responses were examined. Clinical response and serum albumin synthesis were found to be similar in both the groups. The leukocyte (micrograms/10(10) cells) and plasma zinc levels (micrograms/dl) showed a significant (P < 0.001 and P < 0.01) increase from 46.9 +/- 5.490 to 107.2 +/- 13.224 and 80.4 +/- 9.972 to 107.5 +/- 11.822, respectively, after zinc supplementation. The placebo group also showed a significant (P < 0.025) increase in leukocyte zinc from 45.7 +/- 4.409 to 70.9 +/- 8.414. However, the plasma zinc in the placebo group fell from 83.6 +/- 10.363 to 68.2 +/- 7.031. Plasma copper showed a significant improvement in both zinc supplemented (P < 0.01) and placebo (P < 0.025) groups. The results indicate that zinc supplementation along with the diet would result in rapid restoration of zinc status, though there is no effect on the weight gain or other responses.

Effect of reactive oxygen species on the erythrocyte calcium-pump function in protein-energy malnutrition

The presence of detectable amounts of non-heme iron in erythrocyte ghost membranes have been postulated to lead to the initiation of membrane lipid peroxidation and the attendant perturbation of membrane functions. We have investigated the presence of non-heme iron and endogenous products of lipid peroxidation in erythrocyte membranes of normal and kwashiorkor (KWA) subjects and assessed the susceptibility of the membranes to exogenously generated reactive oxygen species. The modulation of the basal and calmodulin-stimulated calcium-pumping activity of these membranes by reactive oxygen species was also assessed. The results show the presence of significant amounts of non-heme iron and endogenous free radical reaction products in the red cell membranes of KWA subjects compared with that of normal children. Estimation of the extent of lipid peroxidation in the presence of exogenously generated reactive oxygen species further revealed that erythrocyte ghost membranes of KWA subjects are more susceptible to oxidative stress than those of normal individuals. Although both the basal and calmodulin-stimulated activities of the membrane-bound Ca(2+)-pump enzyme in normal and KWA subjects were inhibited by oxygen-free radicals, the erythrocyte enzyme in KWA subjects showed higher susceptibility to inhibition by oxygen free radicals than that of normal individuals. We propose that the reduced erythrocyte calcium-pump function in KWA is not unconnected with excessive generation of reactive oxygen species.

Response of Blood Serum Constituents to Production of and Recovery from a Kwashiorkor-Like Syndrome in the Young Pig

Twenty-six 3-week-old genetically obese pigs were fed in two experiments to determine the serum chemistry profile during severe protein malnutrition and repletion. Severe protein deficiency was produced in pigs fed the high-fat, low-protein diet (growth failure, rough hair, low serum total protein and albumin). In Experiment 1, blood was sampled from the anterior vena cava of each pig five times during depletion and three times during repletion to determine serum total cholesterol, high density lipoprotein (HDL)-cholesterol, triglycerides, total protein, albumin, glucose, Ca, inorganic P, Mg, Na, K, Cl, total bilirubin, urea N, creatinine, alkaline phosphatase, alanine aminotransferase, aspartate aminotransferase, and gamma-glutamyltransferase. In Experiment 2, blood was sampled weekly for 8 weeks for serum total cholesterol, HDL-cholesterol, triglycerides, albumin, glucose, Ca, P, Mg and alkaline phosphatase. HDL-cholesterol was increased (P less than 0.01) and albumin was decreased (P less than 0.01) in protein-deficient pigs in both experiments. Creatinine, total bilirubin, gamma-glutamyltransferase, alanine aminotransferase, and aspartate aminotransferase were elevated in protein-deficient pigs compared with controls after 7 weeks of depletion. Inorganic P (P less than 0.01), Ca (P less than 0.01), and Mg (P less than 0.05) concentrations were depressed in protein-depleted pigs compared with controls in both experiments. After 8 weeks of repletion in Experiment 1, all elements except inorganic P were similar in the two groups. Short-term, severe, protein malnutrition affected lipid, electrolyte, and structural mineral metabolism and indices of liver function in the absence of parasites, diarrhea, and infection. The effects were reversed after 8 weeks of repletion. We conclude that the elevated serum cholesterol in protein deficiency is related primarily to an increase in the HDL fraction.

Plasma zinc, copper, selenium, ferritin and whole blood manganese concentrations in children with kwashiorkor in the acute stage and during refeeding

Plasma zinc, copper, selenium, ferritin and whole blood manganese concentrations were measured in 22 children with kwashiorkor on admission to hospital and on days 5, 10 and 30 of refeeding. Twenty similarly aged, healthy, well nourished children served as controls. The mean (SEM) zinc, copper and selenium concentrations of 7.5 (0.93), 10.8 (0.64) and 0.29 (0.02) mumol/l, respectively, in the children with kwashiorkor on admission were all significantly lower than the values of 13.7 (0.66), 25.6 (1.72) and 0.72 (0.04) mumol/l in the controls. In contrast, the erythrocyte manganese level of 1.67 (0.09) micrograms/gHb and the median ferritin concentration of 293 micrograms/dl were significantly higher than in the controls. After 30 days there was full clinical recovery with significant weight gain and a return of the plasma albumin, caeruloplasmin, copper and ferritin to normal. However, manganese remained elevated and zinc and selenium concentrations remained significantly low. Our results suggest that nutritional rehabilitation of children with kwashiorkor is incomplete by 30 days and cannot be judged purely by a return of the plasma proteins to normal. Addition of selected trace elements to the diet may hasten full recovery.